Seminars in Neurosurgery 2001; 12(1): 029-048
DOI: 10.1055/s-2001-12997
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Evaluation and Surgical Repair of Brachial Plexus Injuries

Eric M. Gabriel, Alan T. Villavicencio, Allan H. Friedman
  • Division of Neurosurgery, Duke University Medical Center, Durham, NC.
Further Information

Publication History

Publication Date:
31 December 2001 (online)

ABSTRACT

Traumatic injuries of the brachial plexus may result in severe and permanent loss of motor and sensory function of the involved extremity. The neurosurgeon's ability to improve the functional outcome following a plexus injury requires an understanding of the functional anatomy of the brachial plexus, the pathophysiology of nerve injury, and the natural history of these lesions. Primary reanastomosis, neurolysis, and nerve grafting techniques are commonly used to restore normal axonal continuity. When these options are unavailable, muscle and tendon transfers or neurotization techniques have been successful in achieving functional restoration of limb movements.

REFERENCES

  • 1 Kline D G. Perspectives concerning brachial plexus injury and repair.  Neuosurg Clin N Am . 1991;  2 151-164
  • 2 Solonen K A, Vastamaki M, Storm B. Surgery of the brachial plexus.  Acta Orthop Scand . 1984;  55 436-440
  • 3 Narakus A. Brachial plexus surgery.  Orthop Clin N Am . 1981;  12 303-323
  • 4 Alnot J Y, Jolly A, Frot B. Traitement direct des lesions nerveuses dans les Paralysies traumatiques du plexus brachial chez l' adulte (100 cas operes).  Int Orthop . 1981;  5 151-168
  • 5 Kline D G, Hackett E R, Happel L H. Surgery for lesions of the brachial plexus.  Arch Neurol . 1986;  43 170-181
  • 6 Milles H. Brachial plexus injuries: management and results.  Clin Plast Surg . 1984;  11 115-120
  • 7 Narakus A. Surgical treatment of traction injuries of the brachial plexus.  Clin Orthop . 1978;  133 71-90
  • 8 Millesi H. Brachial plexus injuries: nerve grafting.  Clin Orthop . 1988;  237 36-42
  • 9 Friedman A H. Neurotization of elements of the brachial plexus.  Neurosurg Clin N Am . 1991;  2 165-174
  • 10 Friedman A H. Neurotization. In: Tindall GT, Cooper PR, Barrow DL, eds. The Practice of Neurosurgery Baltimore: Williams & Wilkins 1996: 2909-2921
  • 11 Dubuisson A S. Brachial plexus injuries. In: Palmer JD, Neurosurgery 96-Manual of Neurosurgery New York: Churchill Livingstone 1996: 784-791
  • 12 Coene L N. Mechanisms of brachial plexus lesions.  Clin Neurol Neurosurg . 1993;  S24-S29 ((Suppl)S24-S29)
  • 13 Guha A, Graham B, Kline D G, Hudson A R. Brachial plexus injuries. In: Wilkins RH, Rengachary SS, eds. Neurosurgery, 2nd ed New York: McGraw-Hill 1996: 3121-3134
  • 14 Seddon H J. Three types of nerve injury.  Brain . 1943;  66 237-288
  • 15 Sunderland S. A classification of peripheral nerve injuries producing loss of function.  Brain . 1951;  74 491-516
  • 16 Kline D G, Happel L T. Penfield Lecture. A quarter century's experience with intraoperative nerve action potential recording.  Can J Neurol Sci . 1993;  20 3-10
  • 17 Oberle J W, Antoniadis G, Rath S A, Richeter H-P. Value of nerve action potentials in the surgical management of traumatic nerve lesions.  Neurosurgery . 1997;  41 1337-1344
  • 18 Kline D G. Physiological and clinical factors contributing to the timing of nerve repair.  Clin Neurosurg . 1977;  24 425-455
  • 19 Burge P, Rushworth G, Watson N. Patterns of injury to the terminal branches of the brachial plexus. The place for early exploration.  J Bone Joint Surg . 1985;  67B 630-634
  • 20 Friedman A H, Nunley J AH, Urbaniak J R, Goldner R D. Repair of isolated axillary nerve lesions after infraclavicular brachial plexus injuries: case reports.  Neurosurgery . 1990;  27 403-407
  • 21 Hopkins G O, Ward A B, Barrett R A. Lone axillary nerve lesion due to closed non-dislocating injury of the shoulder.  Injury . 1985;  16 305-306
  • 22 Kline D G, Hudson A R. Diagnosis of root avulsions.  J Neurosurg . 1997;  87 483-483>(letter)
  • 23 Kewalramani L S, Taylor R G. Brachial plexus root avulsion: role of myelography-review of diagnostic procedures.  J Trauma . 1975;  15 603-608
  • 24 Marshall R W, De Silva D R. Computerized axial tomography in traction injuries of the brachial plexus.  J Bone Joint Surg . 1986;  68B 734-738
  • 25 Nagano A, Ochiai N, Sugioka H. Usefulness of myelography in brachial plexus injuries.  J Hand Surg . 1989;  14B 59-64
  • 26 Carvalho G A, Nikkah G, Matthies C. Diagnosis of root avulsions in traumatic brachial plexus injuries: value of computerized tomography myelography and magnetic resonance imaging.  J Neurosurg . 1997;  86 69-76
  • 27 Trojaborg W. Clinical, electrophysiological, and myelographic studies of 9 patients with cervical spinal root avulsions: discrepancies between EMG and Xray findings.  Muscle Nerve . 1994;  17 913-922
  • 28 Tsuruda J, Saloner D, Norman D. Artifacts associated with MR neuroangiography.  Am J Neurorad . 1992;  13 1411-1422
  • 29 Ochi M, Ikuta Y, Watanabe M. The diagnostic value of MRI in traumatic brachial plexus injury.  J Hand Surg . 1994;  19B 55-59
  • 30 Rapoport S, Blair D N, McCarthy S M. Brachial plexus: correlation of MR imaging with CT and pathologic findings.  Radiology . 1988;  167 161-165
  • 31 Filler A G, Howe F A, Hayes C E. Magnetic resonance neurography.  Lancet . 1993;  341 659-661
  • 32 Filler A G, Kliot M, Howe F A. Application of magnetic resonance neurography in the evaluation of patients with peripheral nerve pathology.  J Neurosurg . 1996;  85 299-309
  • 33 Parry G J. Electrodiagnostic studies in the evaluation of peripheral nerve and brachial plexus injuries.  Neurol Clin . 1992;  10 921-934
  • 34 Landi A, Copeland S A, Parry C B, Jones S J. The role of somatosensory evoked potentials and nerve conduction studies in the surgical management of brachial plexus injuries.  J Bone Joint Surg . 1980;  62B 492-496
  • 35 Kline D G, Judice D J. Operative management of selected brachial plexus lesions.  J Neurosurg . 1983;  58 631-649
  • 36 Kline D G, Hudson A R. Nerve Injuries: Operative Results for Major Nerve Injuries.  Philadelphia: WB Saunders; 1995
  • 37 Ducker T B. Pathophysiology of Peripheral Nerve Trauma. In: Wilkins RH, Rengachary SS, eds. Neurosurgery, 2nd ed New York: McGraw-Hill 1996: 3115-3119
  • 38 Kline D G. Civilian gunshot wounds to the brachial plexus.  J Neurosurg . 1989;  70 166-174
  • 39 McGillicuddy J E. Clinical decision making in brachial plexus injuries.  Neurosurg Clin N Am . 1991;  2 137-150
  • 40 Hentz V R, Rosen J M, Xiao S-J. The nerve gap dilemma: a comparison of nerves repaired end to end under tension with nerve grafts in a primate model.  J Hand Surg . 1993;  18A 417-425
  • 41 Henry A K. Extensile Exposure.  Baltimore: Williams & Wilkins; 1957
  • 42 Kaplan E B, Spinner M. Normal and anomalous innervation patterns in the upper extremity. In: Omer GE Jr, Spinner M, eds. Management of Peripheral Nerve Problems Philadelphia: WB Saunders 1980: 75-99
  • 43 Kline D G, Kott J, Bames G, Bryant L. Exploration of selected brachial plexus lesions by the posterior subscapular approach.  J Neurosurg . 1978;  49 872-880
  • 44 Millesi H. Brachial plexus injuries: management and results. In: Terzis JK, ed. Microreconstruction of Nerve Injuries Philadelphia: WB Saunders 1987: 347-360
  • 45 Songcharoen P. Brachial plexus injury in Thailand: a report of 520 cases.  Microsurgery . 1995;  16 35-59
  • 46 Mackinnon S E, Dellon A L. Surgery of the Peripheral Nerve.  New York: Thieme; 1988
  • 47 Samii M, Carvalho G A, Nikkhah G, Penkert G. Surgical reconstruction of the musculocutaneous nerve in tramatic brachial plexus injuries.  J Neurosurg . 1997;  87 881-886
  • 48 Carlstedt T, Risling M, Linda H. Regeneration after spinal nerve root injury.  Restor Neurol Neurosci . 1990;  1 289-295
  • 49 Carlstedt T. Functional recovery after ventral root avulsion and implantation in the spinal cord.  Clin Neurol Neurosurg . 1993;  95 S109-S111
  • 50 Carlstedt T, Noren G. Repair of ruptured spinal nerve roots in a brachial plexus lesion. Case report.  J Neurosurg . 1995;  82 661-663
  • 51 Carlstedt T, Grane P, Hallin R G, Noren G. Return of function after spinal cord implantation of avulsed spinal nerve roots.  Lancet . 1995;  346 1323-1235
  • 52 Clark J MP. Reconstruction of biceps brachii by pectoral muscle transplantation.  Br J Surg . 1946;  34 180-181
  • 53 Steindler A. Orthopedic reconstruction work on hand and forearm.  NY Med J . 1918;  108 1117-1119
  • 54 Meals R A, Nelissen R H H G. The origin and meaning of ``neurotization''.  J Hand Surg . 1995;  20A 144-146
  • 55 Vanlair C. De la generation des nerfs peripheriques par le procede de la suture tubulaire.  Arch de Biol . 1882;  3 379-496
  • 56 Brunelli G A. Direct muscular neurotization. In: Gelberman RH, ed. Operative Nerve Repair and Reconstruction Philadelphia: JB Lippincott 1991: 783-791
  • 57 Morelli E, Morelli A. Injuries of the brachial plexus.  Minerva Chirurgia . 1989;  44 749-754
  • 58 Akasaka Y, Hara T, Takahashi M. Restoration of elbow flexion and wrist extension in brachial plexus paralyses by means of free muscle transplantation innervated by intercostal nerve.  Ann Hand Surg . 1990;  9 341-350
  • 59 Tsuyama N, Hara T. Intercostal nerve transfer in the treatment of brachial plexus injury of rootavulsion type.  Exerpta Med . 1972;  291 351-353
  • 60 Chuang DC-C, Yeh M-C, Wei F-C. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients.  J Hand Surg . 1992;  17A 822-828
  • 61 Nagano A, Tsuyarna N, Ochiai N. Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus.  J Hand Surg . 1989;  14A 980-985
  • 62 Malessy M, Thomeer R. Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery.  J Neurosurg . 1998;  88 266-271
  • 63 Doi K, Sakai K, Kuwata N. Reconstruction of finger and elbow function after complete avulsion of the brachial plexus.  J Hand Surg . 1991;  16A 796-803
  • 64 Allieu Y, Privat J M, Bonnel F. Paralysis in root avulsion of the brachial plexus: neurotization by the spinal accessory nerve. In: Terzis JK, ed. Microreconstruction of Nerve Injuries Philadelphia: WB Saunders 1987: 415-423
  • 65 Kawai H, Kawabata H, Masada K. Nerve repairs for traumatic brachial plexus palsy with root avulsion.  Clin Orthop . 1988;  237 75-86
  • 66 Dumontier C, Gilbert A. Traumatic brachial plexus palsy in children.  Ann Hand Surg . 1990;  9 351-357
  • 67 Gu Y-D, Zhang G-M, Chen D-S. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion.  J Hand Surg . 1992;  17B 518-521
  • 68 Kawai H, Tsuyuguchi Y, Masada K. Identification of the lesion in brachial plexus injuries with root avulsion: a comprehensive assessment by means of preoperative findings, myelography, surgical exploration and intraoperative electrodiagnosis.  Neuro-orthopaedics . 1989;  7 15-23
  • 69 Azze R J, Mattar Jr R, Ferreira M C. Extrapleural neurotization of brachial plexus.  Microsurgery . 1994;  15 28-32
  • 70 Allieu Y, Privat J M, Bonnel F. Paralysis in root avulsion of the brachial plexus. Neurotization by the spinal accessory nerve.  Clin Plast Surg . 1984;  11 133-136
  • 71 Kotani P T, Matsuda H, Suzuki T. Trial surgical procedures of nerve transfer to avulsion injuries of the plexus brachialis.  Exerpta Med . 1972;  291 348-350
  • 72 Allieu Y, Cenac C. Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus.  Clin Orthop . 1988;  237 6774
  • 73 Songcharoen P, Mahaisavariya B, Chotigavanich C. Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus.  J Hand Surg . 1996;  21A 387-390
  • 74 Sedel L. The results of surgical repair of brachial plexus injuries.  J Bone Joint Surg . 1982;  64B 54-66
  • 75 Brunelli G. Neurotization of avulsed boots of the brachial plexus by means of anterior nerves of the cervical plexus. In: Terzis JK, ed. Microreconstruction of Nerve Injuries Philadelphia: WB Saunders 1987: 435-445
  • 76 Brunelli G, Monini L. Neurotization of avulsed roots of brachial plexus by means of anterior nerves of cervical plexus.  Clin Plast Surg . 1984;  11 149-152
  • 77 Narakas A O. The treatment of brachial plexus injuries.  Int Orthop . 1985;  9 29-36
  • 78 Alnot J Y, Oberlin C H. Les Nerts Utilisables pour une Neurotisation. In: Alnot JY, Narakas A, ed. Les Paralysis du Plexus Brachial Paris: Expansion Scientifique Frangaise 1989: 37-42
  • 79 Kanaya F, Gonzales M, Park C M. Improvement in motor function after brachial plexus surgery.  J Hand Surg . 1990;  15A 30-36
  • 80 Samardzic M, Grujicic D, Antunovic V, Joksimovic M. Reinnervation of avulsed brachial plexus using the spinal accessory nerve.  Surg Neurol . 1990;  33 7-11
  • 81 Narakas A O. Neurotization in the treatment of brachial plexus injuries. In: Gelberman RH, ed. Operative Nerve Repair and Reconstruction Philadelphia: JB Lippincott 1991: 1329-1358
  • 82 Yamada S, Peterson G W, Soloniuk D S, Will A D. Coaptation of the anterior rami of C3 and C4 to the upper trunk of the brachial plexus for cervical root avulsion.  J Neurosurg . 1991;  74 171-177
  • 83 Samardzic M, Gmjicic D, Antunovic V. Nerve transfer in brachial plexus traction injuries.  J Neurosurg . 1992;  76 191-197
  • 84 Yamada S, Lonser R R, Iacono R P. Bypass coaptation procedures for cervical nerve root avulsion.  Neurosurgery . 1996;  38 1145-1152
  • 85 Gu Y-D, Wu M-M, Zhen Y-L. Phrenic nerve transfer for brachial plexus motor neurotization.  Microsurgery . 1989;  10 287-289
  • 86 Chuang DC-C, Wei F-C, Noordhoff M S. Cross-chest C7 nerve grafting followed by free muscle transplantations for the treatment of total avulsed brachial plexus injuries: a preliminary report.  Plast Reconstr Surg . 1993;  92 717-725
  • 87 Lurie A. Concerning surgical treatment of traumatic injury of the upper division of the brachial.  plexus (Erb's type). Ann Surg . 1948;  127 317-326
  • 88 Friedman A H. Restoration of extremity function. In: Benzel EC, ed. Practical Approaches to Peripheral Nerve Surgery Park Ridge, IL: American Association of Neurological Surgeons 1992: 209-222
  • 89 Zancolli E, Nlitre H. Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases.  J Bone Joint Surg . 1973;  55A 1265-1275
  • 90 Ploncard P. A new approach to the intercosto-brachial anastomosis in the treatment of brachial plexus paralysis due to root avulsion. Late results.  Acta Neurochir (Wien) . 1982;  61 281-290
  • 91 Dolene V V. Intercostal neurotization of the peripheral nerves in avulsion plexus injuries.  Clin Plast Surg . 1984;  11 143-147
  • 92 Simesen K, Haase J. Microsurgery in brachial. Plexus lesions.  Acta Orthop Scand . 1985;  56 238-241
  • 93 Minami M, Ishii S. Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries: produced by suture of third and fourth intercostal nerves to musculocutaneous nerve.  J Hand Surg . 1987;  12A 1114-1118
  • 94 Morelli E, Morelli A. Injuries of the brachial plexus.  Minerva Chirurgia . 1989;  44 749-754
  • 95 Friedman A H, Nunley J AU, Goldner R D. Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries.  J Neurosurg . 1990;  72 59-64
  • 96 Brunelli G A, Brunelli G R. Direct muscle neurotization.  J Reconstr Microsurg . 1993;  9 81-90
  • 97 Brandt K E, Mackinnon S E. A technique for maximizing biceps recovery in brachial plexus reconstruction.  J Hand Surg . 1993;  18A 726-733
  • 98 Oberlin C, Beal D, Leechavengvongs S. Nerve transfer to biceps muscle using a part of ulnar nerve for C5C6 avulsion of the brachial plexus: anatomical study and report of four cases.  J Hand Surg . 1994;  19A 232-237
  • 99 Krakauer J D, Wood W B. Intercostal nerve transfer for brachial plexopathy.  J Hand Surg . 1994;  19A 829-835
  • 100 Riggins R S. Shoulder fusion without external malfixation. A preliminary report.  J Bone Joint Surg . 1976;  58A 1007-1008
  • 101 Mano Y, Nakamuro T, Tamura R. Central motor reorganization after anastomosis of the musculocutaneous and intercostal nerves following cervical root avulsion.  Ann Neurol . 1995;  38 15-20
  • 102 Giddins G EB, Kakkar N, Alltree J, Birch R. The effect of unilateral intercostal nerve transfer upon lung function.  J Hand Surg . 1995;  20B 675-676
  • 103 Berman J, Anand P, Chen L. Pain relief from preganglionic injury to the brachial plexus by late intercostal nerve transfer.  J Bone Joint Surg . 1996;  78B 759-760
  • 104 Ihara K, Doi K, Sakai K. Restoration of sensibility in the hand after complete brachial plexus injury.  J Hand Surg . 1996;  21A 381-386
    >